using conjoint analysis for the sustainability of the buku...

Title Using Conjoint Analysis for the Sustainability of the Buku KIA(Maternal and Child Health Handbook) Program in Indonesia

Author(s) Ogawa, Sumiko; Eugene, Boostrom; Nakamura, Yasuhide

Citation 名桜大学紀要 = THE MEIO UNIVERSITY BULLETIN(14):291-306

Issue Date 2009-06-30

URL http://hdl.handle.net/20.500.12001/8231

Rights 名桜大学

名桜人学紀安14{'l･6-30(2009)

UsingConjointAnalysュsfortheSustainabilityoftheBukuKIA (MaternalandChild

HealthHandbook)Program inIndonesia

SumikoOgawal',EugeneBoostroml)andYasuhideNakamura2'

1)MeioUniverslty,Okinawa,Japan

2)GraduateSchoolorHumanSciences,OsakaUniverslty,Osaka,Japan

ABSTRACT

To inforllllndoneslan governmentCOnSlderatlOnSregarding continuation and

financingofitsBukuKIA (MaternalandChildHealthHandbook)program afterJICAsupportended,143stafffrom fourpublichealthsystem 一evelsinthreeprovinces

each ranked 27 Cards describing various potentialfeatures ofMCH Handbook

contlnuatlOn.Theyplus56mothersand51communityMCHvolunteersalsoranked27

Othercardsregardingmothers'views,Conjointanalysュsindicatedsimllarltiesamong

allgroupsastofactorsmostinfluencingtheirPreferences,butdifferencesintheir

prerel-redanswersandcharacteristics.Forexample,healthstaffcare"who"wouldbe

keylnaCOntinuedprogram,buteachstaffgroupgaveprioritytoitsownlevel,excepthealthcenterstaffwhofavoredtheprovincelevel.Ⅰmplicationsandsuggestions

to encourage sustainability are discussed in the context of Indonesia-s now

decent.ralizedpublichealthcaresystem andtheimport,anceofhealthcenter･directors

asmanagersanddecisionmakerswithinit.

コンジョイント分析を用いたインドネシアにおける

BUKUKIA (母子健康手帳)プログラムの持続可能性に関する研究

小川寿美子 1)､ユージーン･ブーストロム 1)､中村安秀 2)

名桜大学 ■)､大阪大学大学院 2)

要旨

インドネシアの母子保健状況の特徴は､妊産婦死亡率が高い点である｡その状況改善のため

に､母子健康手帳 (BukuKIA)プログラムがJICAの協力のもと､1993年より開発･試行さ

れてきた｡2002年までにインドネシアの25州に広がり母子健康手帳が多くの妊婦や子供に利用

されている｡

このプログラムの持続可能性を評価するために､2003年2-3月､インドネシア3州のステーク

ホルダー (保健医療スタッフ､母子保健ボランティア､母親など)合計254名を対象に調査を

実施した｡対象者には､母子保健手帳に関する27枚のコンビネーションカード2種類を各々の

優先順位に従い並べ替えてもらい､個人やグループのある事象に対する優先度や選好を計測す

るコンジョイント分析にて解析した｡その結果､母子保健手帳の継続に関し､予算の面で州レ

ベルにドナー依存がより強いこと､また同手帳の配布拠点の要である診療所(Puskesmas)で､

手帳販売による利益を一般7,算に利用したいという意向がより強いことなどが明らかとなった.

一 291-

I . INTRODUCTION

Indonesia is the largest archipelago in the world, with 17,508 islands spread between

the Asian continent and Australia and between the Pacific and Indian Oceans. The

population is 228 million (2006), with a growth rate of 1.5%. The islands are inhabited

by 365 ethnic and tribal groups with diverse cultures. They speak 583 languages,

although the national language, Bahasa Indonesia, is spoken throughout the country.

The other principal languages are Acehnese, Bataks, Minangkabaus (all in Sumatra),

Javanese, Sundanese (Java), Balinese (Bali), Sasaks (Lombok), and Dani (Irian Jaya).

The population is 87% Muslim, 9% Christian, 2% Hindu, and 2% others and unspecified

(Population Resource Center, 2004).

An important objective of the government of Indonesia is to reduce the maternal

mortality and under-five mortality rates as much as feasible in the shortest possible

time. One of the strategies to achieve this has been the development of an integrated

management approach within the health system, including hospitals, health centers,

and the community and family levels (JICA, 2005). Therefore the Ministry of Health

of Indonesia, in collaboration with the Japan International Cooperation Agency

(JICA), developed a strategy for integrated maternal and child health services usmg

an MCH Handbook. The aim of this strategy is to Improve the quality of MCH

services, providing better access to MCH services and educating the community and

family as to how and when it is appropriate to seek care (including preventive

services) or to practice home care (JICA-Indonesia, 2005)

Since its successful beginning in a pilot area with a population of 150,000 in

Indonesia's Central Java Province in 1993, the Maternal and Child Health Handbook

Program first expanded to cover two thirds of the province's population, then all 35

of its districts/municipalities and the cities of Central Java Province, and finally to

cover other provinces. By 1998, the program covered a population of 18 million (Osaki

et al 1998).

In 1997, Indonesia's Director General of Public Health, considering the "concept" of

MCH Handbook applied in Japan, developed a "generic" Indonesian MCH Handbook,

combining both health education and health record functions and with various

original aspects. The handbook was intended for use at the family level in a health

care system emphasizing primary health care and for adaptation to meet the specific

needs of each province. As of December 2002, the MCH Handbook had been introduced

and distributed in 25 of Indonesia's 30 provinces.

Osaki et al (1998) delineated five points that they felt contributed to the success and

expansion of the program

Firstly, the program's concept, the sense of ownership toward the program

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and the consideration of its adaptability to local sites were correct. Secondly,

there was a need for this program In each related group, namely policy

makers, implementing personnel and its beneficiaries. Thirdly, resources and

infrastructure were adequately arranged to support community health

serVIces. Fourthly, efforts were made to ensure the sustainability of the

program and finally, the role of catalyst in the program was performed

effectively by the Japanese side.

II. OBJECTIVE

To ascertain staff, client and MCH volunteer VIews of and preferences regarding

options (including user fees) for expansion of MCH Handbook usc in Indonesia after

the end of JICA funding for the program.

m. STUDY AREAS AND SAMPLES

Six districts in 3 prOVInces were selected as the study areas: Badung and Gianyar

districts in Bali Province, Mojokerto and Blitar districts in Java Timur, and Kulon

Plogo district and Yogyakarta City in Yogyakarta Province. All were in areas of the

island of Java in which the program had been implemented since the early 1990's.

The 254 participants were selected from seven groups at six levels: there were three

from the central Ministry of Health office responsible for the project, 12 from the 3

provincial health offices, 18 from the 6 district/city health offices, 47 directors and 67

midwives from health centers (Puskesmas), and 51 MCH volunteers (Kaders) and 56

mothers from the selected districts (Table 1).

Table 1 Numbers of Participants In the Simulation, by LevelsHealth Health

MCH TotalCard MoH Province District Center Center

VolunteersMothers*

participants..

Director Midwives

A 3 12 17 47 64 --- --- 143

B 3 11 18 46 67 51 56 252

'Note: "Mother" includes currently pregnant women and women who delivered within the last five years,all of them with experience with the MCH Handbook.

"Note: Total participants were 254; however, two provincial health officers only answered Card A butnot Card B.

N. ABOUT CONJOINT ANALYSIS

Conjoint Analysis (CA) provides an efficient way to learn about and compare

different groups' perspectives regarding the relative importance of several sets of

questions in the provision of a good or a service and also indicates their preferred

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answers to those questions (Ryan 1999).

CA is an application of "Multi-attribute Utility Theory" (2). CA has been widely

accepted and applied in marketing research, transportation and environmental work

since the 1970's, especially for practical decisions (Cattin 1982). In the United States

CA has been used by non-economists within the area of health care to examine factors

important to patients in the provision of health care services (McClain, 1974; Parker,

1976; Wind, 1976; Chakraborty, 1993). In the UK it has been used to estimate the

monetary value of reducing time spent on waiting lists (Propper, 1990), the trade-offs

individuals would make between the locations of clinics and waiting time in using

orthodontic servIces (Ryan, 1997), and patient preferences III the doctor-patient

relationship (Vick, 1998).

V. METHODS

1. ESTABLISHING THE QUESTIONS

Two scenarios were prepared and used with members of seven groups at SIX health

Table 2 Simulation "A" Cards: Sustainability and Continuation or Expansion of Useof MCH Handbook - Views of Civil Servants *

Questions ("Attributes"), forAnswers ("Levels"). one of which appears on each cardeach of which one flAnswer"

is included on each card·· for each question*

1-1 Ministrv of Healthl-Who is the key person to 1-2 Province

sustain this MCH Handbook 1-3 District local oovemorprogram? 1-4Dis!nct health office

1-5 Health centers2-Who will take the major role in 2-1 All Province budee!

financial support to continue 2-2 Province budoet > Donor suooortthe MCH Handbook's 2-3 Province budoet and Donor suooort. eouallvproduction, distribution and 2-4 Province budeet < Donor supoortuse? 2-5 All Donor support

3-What is the amount of the user 3-1 Free of charge to all mothersfee you expect to collect from 3-2 Rp.2,500 •••mothers? 3-3 Full cost ••••

4-1 Deposit fee at district local office and use it to print

4-Which is the best use for the Handbook

money collected as user fee 4-2Deposit the fee at district health office and use it to printthe Handbookfor the MCH Handbook?4-3 Keep fee at health center and use it as oeneral budeet4-4 Use it to subsidize/provide free health care for the poor

5-00 you think the handbookimproves mothers' knowledge 5-1 Improvement

and positively changes theirbehavior? 5-2 No improvement

6-00 you think it is necessary to 6-1 Training necessaryprovide a training to your staffand/or MCH volunteers for the 6-2 Training not necessaryHandbook's sustainable use?

)\!ote': Instruction to participants for use of the cards: "In September 2003, .JICA funding for theMCH Handbook project will end. What is the best service package/combination to sustain andexpand provision of the MCH Handbook after that? Please rank these 27 cards according toyour preferences."

Note": Each card contains one pre-selected answer per question. The combination of answers oneach card was selected statistically by SPSS to produce an orthogonal design suitable forConjoint Analysis.

ate"': Rp (Indonesian currency Rupia) 2,500 was equivalent to 0.25 US dollar in February 2003.Note"": Full cost of the MCH Handbook depended on the districts/municipalities, and each group

of respondents was informed before sorting the cards of the specific cost of thc Ilandbook intheir district or municipality. The average full cost was RpAOOO (0.40 US$).

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system levels. The first scenario, regarding "Sustainability", was used with five of the

seven groups, excluding mothers and MCH volunteers. In discussions with the MOH,

JICA and others, six questions for the first scenario and card set, along with

alternative answers to each question, were selected on the use, management and fi

nancing of the MCH Handbook. They are shown in Table 2.

The second scenario was used with all seven groups. In discussion with the MOH,

JICA and others, four questions (with alternative answers) were selected regarding

MCH Handbook-related activities from mothers' viewpoints. They are shown in Table

3.

Table 3 Simulation "B" Cards: Mothers' first pregnancy visits and mothers' opinions ofMCH Handbook and willingness to pay for it (and health workers' and officials' opinions as to what the mothers' views would be)*

Questions ("Attributes"), for each of which one "Answer" is Answers ("Levels"), one of which appears on eachincluded on each card** card for each auestion***

1-1 Health center1-2 HosDital

1-Where do you visit at first when you get pregnant? 1-3 Midwife Clinic Private1-4 Public Midwife Station1-5 Traditional Birth Attendant2-1 Free of charge to all mothers

2- Are you willing to pay for the MCH Handbook? (HOW much?) 2-2 RD.2,500·..•2-3 Full cosr....

3- Do you feel you get a lot of knowledge through the MCH 3-1 YesHandbook? 3-2 No

4-Do you want to be given training to better understand the MCH 4-1 Want training

Handbook's contents?4-2 Do not want training

Note': Instruction to partlClpants for use of the cards: "(If you were a mother of an average familyin your area,)' How do (would) you feel about the services related to the MCH Handbook')Please rank these 27 cards according to your preferences among the health service combinations on the cards."

Note": The parenthetical part of the instruction is used for all participants EXCEPT the mothers.Note''': Each card contains one pre-selected answer per question. The combination of answers on

each card was selected statistically by SPSS to produce an orthogonal desig'n suitable forConjoint Analysis.

Note'''': Rp (Indonesian currency Rupia) 2,500 was equivalent to 0.25 US dollar in February 2003.Note"": Full cost of the MCH Handbook depended on the districts/municipalities, and each group

of respondents was informed before sorting the cards of the specific cost of the Handbook intheir district or municipality. The average full cost was RpAOOO (OAO US$).

2. LANGUAGES

All materials and instructions were produced, distributed and used in Indonesia's

national language, Bahasa Indonesia. All health staff and MCH volunteers, and

almost all mothers, could read Bahasa Indonesia.

However, six mothers could read little or no Bahasa Indonesia and therefore needed

help in understanding what was written on the cards; that help was provided by local

health center staff members, one of whom sat beside each such mother to translate

Bahasa Indonesia, item by item, into a local language that both the mother and the

staff member spoke and understood well.

3. POSSIBLE ANSWERS TO THE QUESTIONS

Issues considered in defining the proposed answers for each question included

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identification of the appropriate ranges for alternative answers, intervals to be used in

quantitative answers, and specification of qualitative answers.

Obviously the alternative answers to each question needed to be realistic, both alone

and in combination with answers to the other questions. The questions and the

alternative answers also needed to be conceived and structured in such a way that

individuals would be willing to consider tradeoffs among them (Okamoto, 1999).

4. PRESENTATION OF SCENARIOS

The questions ("attributes" in the CA literature) and answers ("levels" in the CA

literature) presented in Tables 2 and 3 give rise respectively to 1200 (5x5x4x3x2x2) and

60 (5x3x2x2) possible non-identical scenarios. The SPSS procedure Orthoplan (SPSS

ver.10J) was used to reduce these to "manageable numbers" while still being able to

infer preferred answers ("utilities") for all possible scenarios (Sanagi, 2001). The

procedure results in an orthogonal main effects design(\) and gave rise to 27 scenarios

each from the original 1200 and 60 respectively. Each participant divided those 27

cards into 3 groups: "preferable", "not preferable", and "neither". Each participant then

ranked the cards within each of her or his groups of cards according to her or his

preferences, and the three ranked groups were combined to see that participant's

overall ranking order for all 27 cards.

VI. RESULTS

1. OVERVIEW

Of the 254 individual participants, 143 sorted the simulation "A" cards (i.e., all but

the MCH volunteers and the mothers), and 252 sorted the simulation "B" cards. (Two

provincial health officers sorted only the simulation "A" cards.)

Average Importance indicates the influence of each question in terms of the partici

pants' rankings of the 27 cards in each simulation. Relative Importance and utility

scores for each of the various questions in Simulations A and B are summarized in

Tables 4 and 5, respectively. The two tables show findings for all groups of partici

pants, although all other figures later in this paper omit the data for the Central

MOH group because it included only three respondents and their responses differed

too much to consider them as a group.

For Simulation "A" cards, all groups gave the most importance to "Keyman"

(Provinces: 24.58%, Districts: 24.13%, health center directors: 25.22%, and health center

midwives: 26.0%) except the central MOH group (23.88%), which gave slightly more

importance to "Budget source" (24.93%). The second most important was "Utilization of

user fee" in both Provinces and Districts (21.94% and 20.75%, respectively), however,

both Directors and Midwives at health centers considered "Budget source" to be the

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Table 4. Conjoint Analysis Outputs of Card A:Continuation and Funding of the MCH Handbook

Question 1 Kev erson to sustain MCH Handbook Proaram ?

Average Importance 23.88 24.58 24.13 25.22 26

Grauo of Particioants MOH Three Provinces Six Districts Health Center Directors Health Center Midwives

Health center -0.6 -1.3333 0.1647 -0.5191 -0.1719

District health office -1.5333 -0.95 0.1647 -0.1362 -0.3031

District local aovernor 0.7333 0.5833 0.6118 0.0426 -0.4656

Provincial health office -1.2667 0.7667 -0.2235 0.4936 1.0687

Minlstrv of Health 2.667 0.933 -0.7176 0.1191 -0.1281

Question 2 FundinQ future MCH Handbook nro ram?

Averaae Imoortance 24.93 15.94 19.76 22.85 21.41

Group of Participants MOH Three Provinces Six Districts Health Center Directors Health Center Midwives

All oravinclal budaet iPe} -2.333 -0.3021 -0.3676 0.5638 0.4336

More PB than donors -1.933 -0.0104 0.2912 0.2617 -0.5477

Less PB than donors 2.2 -0.2771 1.0324 -0.8362 0.1336

All donors 2.0667 0.5896 -0.9559 0.0106 -0.0195

Question 3 User fee amount eXDect to collect?



No charae 0.9333 OA006 0.8431 ~0.3284 0.5328

Pay 2 500 RD. -1.1 0.2556 -1.3039 -0.0475 -0.3297

Pav full cost 0.1667 -0.7361 0.4608 0.3759 -0.2031

Question 4 Best use of collected money ?



Print by District Office 1.75 0.5104 00368 0.0346 0.9277

Print bv District health office -0.3833 -0.5146 0.5485 -0.1335 -0.9551

Use money for HC's runnlna cost -1.1167 0.4854 -02279 0.6239 -0.102

Use monev for the Door at HC -0.25 -0.4813 -0.3574 -0.525 0.1293

Question 5 Imoroves mothers' knowledae & behavior with MCH Handbook?


Graue of Particieants MOH Three Provinces Six Districts Health Center Directors Health Center Midwives

Yes 0.4444 0.3194 1.1127 -0.0691 -0.0156

No -0.4444 -0.3194 -1.1127 0.0691 0.0156

Question 6 Training needed bv staff/MCH volunteers for MCH Handbook?



Need 0.6667 -0.1042 0.0196 -0.1294 -0.0885

No need -0.6667 0.1042 -0.0196 0.1294 0.0885

Table 5 Conjoint Analysis Outputs of Card B:Mothers Views of MCH Handbook and Willingness to Pay'

Question 1 First visit in oreanancv where?

Averalle Importance 44.16 49.57 47.73 45.9 46.45 49.94 48.49

Three Provinces Six Districts Health Center Health Center MCHMothers

Group of Participants MOH Directors Midwives Volunteers

Health center 3.733 0.2909 1.6111 0.4783 0.1672 0.7176 1.3679

HOSDital -2. 0.0364 0.1222 -0.2 -0.1821 -0.702 -0.9536

Private Midwife clinic -1. 0.0545 0.6889 -0.1522 0.2925 -0.0314 -0.0393

Public Midwife Station 0.733 ~0.9455 -0.6444 0.7174 -0.1493 0.298 0.3679

raditlonal Birth Attendant -0.466 0.5636 1.7778 -0.8435 -0.1284 -0.2824 -0.7429

Question 2 User fee Willinaness to av?

AveraQe Importance 37.78 29.34 23.29 25.55 26.78 24.24 25.54

Three Provinces Six DistrictsHealth Center Health Center MCH Mothers

roun of Particioants MOH Directors Midwives Volunteers

No charae 0.455E 0.9242 -0.1907 -0.4978 -0.0891 -0.366 -0.5083

Pav 2 500 RD. 1.988 0.9242 -0.4574 0.4543 -0.0726 -0.6209 0.1363

lPav full cost -2.444 -1.8485 0.6481 0.0435 0.1617 0.9869 0.372

Question 3 Much knowledae throu h MCH Handbook?

Averaae Imoortance 5.52 10.64 1465 14.02 12.23 12.34 13.16

broue of ParticieantsThree Provinces Six Districts

Health Center Health Center MCH MothersMOH Directors Midwives Volunteers

es -0.138 0.4697 -0.5 -0.2283 0.2711 0.2745 0.0432

No 0.138~ -0.4697 0.5 0.2283 -0.2711 -0.2745 -0.0432

Question 4 Want Trainina ?Averaae Imoortance 12.53 10.45 14.32 14.53 14.55 13.48 12.81

broue of ParticieantsThree Provinces Six Districts

Health Center Health Center MCH MothersMOH Directors Midwives Volunteers

Want 0.722 -0.2273 -0.2037 -0.4601 -0.3085 -0.2843 0.1354

Not want-0.722 -0.1354

'Note: For groups other than the mothers themselves, the groups answers represent theirperceptions as to the mothers' views regarding each question.

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second most important (21.43% and 20.87% respectively).

In Simulation "B", regarding mothers' views and health staff perceptions of those

views, for all seven groups the same question, "First visit in Pregnancy", was the most

important one in ranking the cards, with very high relative importance (range:44.16%

- 49.94%). The second most important question was also the same for all groups, "User

Fee Willingness To Pay" (range 23.29% - 37.78%) ..

Both "A" and "B" cards include questions asking about "User Fee" (question 3 in "A"

and question 2 in "B "), "Improvement" (question 5 in "A" and question 3 in "B"), and

"Training" (question 6 in "A" and question 4 in "B"). However, of those questions only

"User Fee" showed relatively high importance (11.13% - 37.78%). The others generally

were not very important for the participants' rankings of the two sets of 27 cards;

with low ranges of average importance for the various groups both for "Improvement"

(5.52% - 14.65%) and for "Training"(6.81% - 14.53%).

2. RESULTS: SIMULATION "A" CARDS

Simulation "A" cards are the scenarios of public health staff VieWS of the relative

importance of several factors related to the MCH Handbook's sustainability. Figures

1-1 to 1-6 show the relative preferred answers, by group, for each question.

The central MOH group is excluded from the figures because only three MOH officials

ranked the cards and there was little consistency among the three. These figures show

both positive (above zero) and negative (below zero) preferences, which indicate what

answers the participants selected/rejected as they ranked the 27 cards. The longer

bars show stronger positive/negative preference in selecting answers than the shorter

bars; for example, the leftmost bar in Figure 1-1 indicates that the group of three

provmces considered Health Centers to be the least preferable 'Key person' to sustain

the MCH Handbook (score: -1.33), and "District Health Office to be the second least

preferable (score: -0.95). On the other hand, they considered the MOH to be the most

preferable "Key person" (score: +0.933) and "Province" the second most preferable

(score: +0.766).

Each of the figures shows findings for one question; answer preferences are

indicated by the blocks within a vertical bar for each group. In response to Question

1, i.e., "Key person to take role for sustainability of MCH Handbook", each level feels

itself to be the "key person" for sustaining the MCH Handbook, except directors and

midwives of health centers (Figure 1-1). As for Question 2 ("expectation of funding

resources"), higher levels prefer to depend on donor support for the MCH Handbook

program, whereas both types of health center staff responding prefer to depend on

provincial budgets (Figure 1-2). For Question 3 on "User fee amount", only health

center directors would prefer to collect user fees covering full cost, and the others

would prefer to provide the MCH Handbook free of charge (Figure 1-3). In Question

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Three Health Center Health CenterProvinces Six Ostricts Drectors Mdw ives

e~m>.!.g~ -1i!.. -2

-3

Three Health Center Health CenterA'ovinces Six Districts Orectors Mdwives

e 1.5

~~

I~ 0.5

~:t~

~

~ ~O.5

~.. -1

-1.5

o Health CenterB~ict local Governero District Health Officeo A"ovncial Health Office • AU provincial budget (Fa) • M:>re Fa than donor funds

II less Fa than donor funds OAI donors

Figure I-I: Answers to Question I:Key Person for MeH Handbook's sustainability

Figure 1·2: Answers to Question 2:Funding resources

1.5

Three Health Center Health Center

Provinces Six Districts Directors Mdw ives

e~.~ 0.5

! a

~-0.5E.! -1E..

-1.5

Three Health Genter Health GenterA'ovinces Six Districts Directors Mdwives

e 1.5

~

~~ 0.5

~ ~ ~~

~E-0.5

i -1..-1.5

Of\b charge o pay 2,500 Rp. o Pay full costl1J A'int by District Office [J A'int by District health officeo Use m:mey for t-Cs running cost~ Use rmney for the poor at I-C

Figure 1-3: Answers to Question 3:Usc.. Fee Amount

Figure 1-4: Answers to Question 4:Fcc Best Usc

-1

.,.51

0.15

Three Pealth center realth center

A"ovinces Six Ostricts Orectors Mdw ives

I 01

~ 0.05

:;!'"B-O.05~

~i -0.1..-0.15

HeaItt1Center

Mdwives

HeaItt1Three Center

Rovinces Six Dstricts Drectors

e 1.5

8'"~ 0.5

~III -0.5

11E

i..IIJi'bNeed

Figure 1-5: Answers to Question 5:Improves Mothers' Knowledge and Behavior

Figure 1-6: Answers to Question 6:Training Needed by Staff

Figure 1-1~1-6 Preferable Answers to Questions (1-6) in Simulation A Cards

4, "Fee best use", health center directors would prefer to utilize the user fee for

general budget at their working place, the health center; however, the others would

prefer to use the money collected as fees to pay to reprint the MCH Handbooks

(Figure 1-4). For question 5 ("Improves mothers' knowledge and behavior"), staff at

higher levels of the Public Health system perceIve more Handbook-related

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improvement In mothers' knowledge and behavior than do directors and midwives at

health centers (Figure 1-5). For Question 6, "Training Needed by Staff", in general,

public health staff perceive little need for further staff training to sustain and expand

the use of the MCH Handbook (Figure 1-6).

3. RESULTS: SIMULATION "B" CARDS

Simulation "B" cards are the scenarios of MCH Handbook-related activities from the

users' or mothers' viewpoint. Figure 2-1 shows that both mothers and MCH volunteers

answer "Health Center" for the first contact in pregnancy. However both directors and

midwives at health centers, at the frontline, believe respectively that mothers prefer

private urban midwife clinics and public rural "Polindes" midwife posts for first visits

in pregnancy. It is possible that mothers and MCH volunteers participating in the

study were not representative of all eligible mothers since they were supposed to be

gathered from near the health centers.

Figure 2-2 indicates that the mothers are ready to pay full cost of the MCH

Handbook (an average of Rp. 4,000 but varying among provinces and even among

districts), or at least Rp.2,500. The amount of Rp. 2,500 as a user fee for the MCH

Handbook was also found to be acceptable to mothers in a previous survey, and

discussions with staff during this survey indicated that it corresponds to the average

fee charged in those provinces and districts that already impose such a charge. Public

health staff agree that mothers are willing to pay at least Rp. 2,500, except that

Province level respondents believe mothers unwilling to pay.

As for mothers' improved knowledge and behavior as a result of the MCH

Handbook, mothers themselves see some handbook-related improvement, and MCH

volunteers, midwives and provincial health officials believe that mothers see such

improvements, whereas the others feel that mothers do not see such improvements

(Figure 2-3). Views regarding mothers' desire for training in order to know more

about the MCH Handbook's contents are shown in Figure 2-4, which indicates that

although mothers want to learn more about the MCH Handbook's contents (through

small seminars organized by MCH volunteers and/or health center staff), none of the

other groups are aware of the mothers' desire for such training; both the mothers and

the health staff were aware that training sessions had been organized under the

program, taught by health staff and MCH volunteers, to help mothers understand the

advantages of using the MCH Handbook to improve their health practices.

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llYeI Heelflc... HeelIhC..,. MCHPr"",~ Sixo.P1C:tS Olrectel', 1.1._ \kII~ ~ - -Th'ee eer. CerW MCH

Pr""'rctII Sillo.st1ds o.reda's MiOM_ \kIItrIWlrs

C Heath center II ftlspilalrdRivate Mdwife cinic IS AJblic Mdwife Stationo Traditional Birth Attendants

2.5_ 2

~ 1.5~ 1v~O.5

~ 0

~O.5c -1~~1.5

a: -2

-2.5

E1l\bcharge

I •

Ilf\ly 2.500~. lJ Pay full cost

Figure 2-1: Answers to Question I:First Visit in Pregnancy

T1YM HellIIhCenlerHeel...C..,. MCH

"'~~ Six DIstricts o.rectn M..._ "'....... Mdt,..

06

I"j

I I IQ)0,2

I.~

:iii •~O

~

go>~

0$.0.4

£-06

Figure 2-2: Answers to Question 2:User Fee Willingness to Pay

- -~Tlree Cer&er c... MCHProloiroas SlxDislriets Directors MiOi.i_ VdlJ1loerl Mdhllrl

0.6

I I

liN:> II YES • Want II!lNXwant

Figure 3-1: Answers to Question 3:Much Knowledge through MeH ~Iandhook

Figure 2-4: Answers to Question 4:Mothers Want Training

Figure 2-1~2-4 Preferable Answers to Questions (1-4) in Simulation B Cards

VII. DISCUSSION

In general, in order to sustainably provide servIces or goods usmg funds from an

autonomous revolving fund, it has been recommended (Cross 1983) that the system

collect, circulate and use money efficiently and track it through the use of a

transparent accounting system . In the case at hand, m order to minimize losses it

would also be necessary to track the movements and losses of MCH Handbooks, as

well as user fee monies, throughout the cycle. Figure 3 depicts such a system, which

could help free the provision of the MCH Handbook from dependence on donor funds.

On the other hand, an impression of the present condition of the MCH Handbook

prOV1SlOn IS that the revolving cycle mainly depends on donor inputs (especially from

JICA), and that there are several points within the cycle with high potential for

handbooks or funds to be lost, stolen, and missing; for example some MCH

Handbooks may be left unused at provincial offices and at health centers, some

mothers do not utilize the handbooks, and some of the collected fee monies are used

for other purposes either at health centers or district levels. Due to those "external"

losses, the cycle grows weaker and the losses lead to or increase the need to supply

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Figure 3: Ideal cycle for autonomous sustainability withUser fee and the Revolving Fund of MCH Handbook

CASH

....... USER FEES

SUBSIDIZE

IPRINTING

MOTHERS'

HANDS

DELIVER TO

~~ioiI!'I~..,..HEALTHCENTER

HAND BOOK FLOW

~ CASHFLOW

additional funds in order to sustain the system and provide the MCH Handbook.

The main recommendations that can be offered in the context of Indonesia's public

health system on the basis of the findings of the Conjoint Analysis and related

observations and discussions can be summarized as follows:

1) All levels should consider how to respond to the Mothers' felt need for education

and training regarding the information in the MCH Handbook, as an opportunity

to improve service quality and mothers' knowledge, attitudes and practices in and

through the program. Potential providers of MCH Handbook training for mothers

might benefit from receiving training and training materials themselves on how to

build upon the mothers' desire to learn and on how to effectively help mothers to

understand and apply key MCH Handbook contents and messages.

2) To reach more mothers, the MCH Handbook could be distributed not only to and

through health centers, but also through public and private midwives.

3) The MCH Handbook program began under a centralized system, which has now

been decentralized under a national government decentralization program which

began officially in 2001; both MOH and general governmental decentralization have

major implications for MCH Handbook continuation. At the periphery of the

system, there have been major changes in funding channels, increased freedom from

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central control in the use of funds and other resources, and an increasing need for

health officials to consider the interests and objectives of non-health officials at

their own and immediately higher levels upon whose decisions and actions they now

depend for support. For example, health center funds now come from or are

channeled through the provincial level. Health center directors' views regarding the

MCH Handbook program and its continuation and funding differ from the others'

views. Under the increasingly decentralized system, all need to recognize the health

center directors' (the de facto decision makers') willingness and intention to treat the

User's fee as general budget resources for the health center, not for printing

Handbooks. Also, health center directors tend to have more clinical interests than

management interests, while decentralization requires that certain currently weak

management systems, functions and skills be developed and effective at peripheral

levels, including for example accounting.

4) High level Public Health officials need to seek alternative (non-JICA) financial

resources for the MCH Handbook. Increased government, public and health staff

recognition of the MCH Handbook's benefits are likely to be important in success

fully obtaining those resources.

Figure 4 shows flows within what could be a sustainable system to continue and

pay for the MCH Handbooks with greatly reduced or no donor support.

Under the present conditions of unsystematic user fee collection, and gIven the

health center directors' willingness or intention to utilize the user fee as general

budget, user fees might not be able to provide the main financial resources for the

MCH Handbook's continuation. As health center level responses indicate, the "provin

cial governor's budget" might have the greatest potential as a source of funds to

sustain the provision of MCH Handbooks after JICA withdraws as the main donor.

In order for those funds to be made available, it would be crucial to obtain political

support from the governor's office. The MCH Handbook would also need to be

well-recognized both by users and by health care managers and providers as making

significant contributions to improving the health of mothers and children. It might

be possible to reduce the MCH Handbook's overall design and printing costs, thereby

reducing the potential financial burden on each provincial governor; for example, the

MOH might to a greater extent standardize the contents and inner parts of the

Handbook so as to facilitate either central printing or cheaper setup for printing at

any other level, and encourage and assist each province to simplify its handbook's

cover page and introductory pages, for example not using color photos but rather

only limited-color line drawings, as has been done with the Japanese MCH Handbooks

for the last 50 years.

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Figure 4: Feasible cycle to sustain MCH Handbook programwith combination of user fee, local budget and greatreduction of donor funds

MISSING

PROVINCIAL BUDGET

(MAJOR FINANCIALI RESOURCE)

PRINTING

INCENTIVE

BUDGETAT HEALTH

CENTER LEVEL

USER FEES

CASH

EXEMPTIO

FROM

USERFEE

PAYMENT \jMOTHERS'

HANDS

DELIVER TO

~!!Mioiiilo!ii~ HEALTHCE TER

STOLEN OR LOST

HAND BOOK FLOW

..... CASHFLOW

Note': Utilization of the User Fee to provide incentives at the Health Center level is likely to be demanded by Health Center Directors, judging from their responses in the simulation. This appears to be mainly because of the limited budgets at Health Centers following health sectordecentralization in 2001.

ACKNOWLEDGEMENTS

The authors would like to thank BALITA/Depkes (the Under-Five Children Section

in Indonesia's Ministry of Health) in Indonesia, for their support during the study, as

well as thanking all the participants who cooperated in the study and the public

health staff who also gave of their time to provide information in each study area.

Dr. Akiko Takaki, Team Leader of the MCH Handbook Project, long term Experts

Ms. Noriko Toyama and Ms. Tomoko Hattori, and JICA Senior Health Advisor Ms.

Saeko Hatta provided invaluable information and advice and also constructive

comments on the questionnaire. Ms. Ade Erma, Program Assistant, was extremely

helpful in both translation and interviewing.

The first author expresses her thanks to Associate Professor Akiko Matsuyama,

Center for International Collaborative Research, Nagasaki University, for supporting

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her 2003 mission as a chief advisor of the JICA project in Indonesia.

The data on which this paper is based were collected during the first author's short

term mission to the MCH Handbook Project in Indonesia under the Japan

International Cooperation Agency (JICA) in 2003. The views expressed in this paper

are, however, entirely those of the authors and do not necessarily reflect the policies

or views of JICA.

Notes:(1) In a typical CA study individuals are presented with hypothetical scenarios involving different

levels of attributes which have been identified as important in the provision of a good or serv

ice and asked to rank the services, rate them. Within market research ranking and rating ex

ercises have proved the most popular. Transport economists developed the pairwise companson

approach from the economic theory of random utility (McFadden, 1973).

(2) Definition of orthogonal is as follows: Let "i" and "j" be two levels of attribute A, and "k" a

level of attribute B; then:

# of products having A 1 paired with Bk / # of products with A i

# of products having A j paired with Bk / # of products with A j.

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